Abstract S3-07: Impact of radiotherapy on complications and patient-reported satisfaction with breast reconstruction: Findings from the prospective multicenter MROC study

Background: Patients considering both post-mastectomy radiation (RT) and reconstruction require robust information regarding the expected outcomes of different combinations of approaches in order to make preference-concordant decisions.

Methods: In a prospective multicenter cohort study (the Mastectomy Reconstruction Outcomes Consortium, MROC, funded by NCI 1RO1CA152192) of women diagnosed with breast cancer at 11 institutions between 2012-15, we compared responses of 553 radiated and 1461 non-radiated pts who received different approaches to reconstruction. The primary dependent variables of interest were development of any breast complications (e.g. hematoma, wound infection) by one year post-reconstruction, along with satisfaction measured with the validated BREAST-Q instrument. Mixed-effects regression models assessed impact of reconstruction type and RT on the outcomes of interest. Covariate adjustment included reconstruction timing, age, extent of disease, bilateral vs unilateral treatment, chemotherapy receipt, nodal management, BMI, smoking, diabetes, race, ethnicity, education, employment, income, marital status, and hospital site.

Results: Median age was 49. Bilateral mastectomy was received by 45.6% of radiated and 53.3% of non-radiated pts (p=0.002). Autologous reconstruction was more commonly received by radiated pts (38.3% vs 25.1%, p<0.001). Immediate reconstruction was less common in radiated pts (82.6% vs 95.6%, p<0.001). By one year, at least one complication occurred in 28.8% of radiated pts (30.8% of implant pts and 25.5% of autologous pts) and 22.3% of non-radiated pts (20.4% of implant pts and 28.1% of autologous pts). Among pts with ≥2 years of follow up, a complication had occurred by 2 years in 34.1% of 331 radiated pts vs 22.5% of 946 non-radiated pts. Multivariable analysis showed immediate reconstruction, bilateral treatment, & higher BMI to be predictive of developing a complication by one year. RT effect differed by reconstruction type; RT was associated with 2.1 (95% CI = 1.45, 3.10) times higher odds of complication in implant pts, while showing no difference in autologous pts (OR=1.3, 95% CI = 0.76, 2.09). RT effect on patient outcomes also differed by reconstruction types. In implant pts, adjusted mean BREAST-Q satisfaction with breast scores were significantly lower in radiated pts than in non-radiated pts (51.5 vs. 58.0 at 1 year, p<.001; 48.9 vs. 59.8 at 2 years, p<.001), while satisfaction in autologous pts did not differ by radiation (61.3 in radiated vs. 63.5 in non-radiated at 1 year; 62.8 vs. 65.8 at 2 years). Similarly, in implant pts, satisfaction with outcomes was significantly lower in radiated versus non-radiated pts (66.5 vs. 70.8 at 1 year; p=0.03; 64.4 vs. 70.6 at 2 years, p =0.03), while there were no significant differences in autologous pts (72.7 vs. 75.2 in radiated vs. non-radiated at 1 year; 71.3 and 75.3 at year 2).

Conclusions: In the largest prospective multicenter study of outcomes of breast reconstruction to date, autologous reconstruction appears to yield superior patient-reported outcomes and lower risk of complications than implant-based approaches among patients receiving PMRT.

Citation Format: Jagsi R, Momoh AO, Qi J, Hamill JB, Billig J, Kim HM, Pusic AL, Wilkins EG. Impact of radiotherapy on complications and patient-reported satisfaction with breast reconstruction: Findings from the prospective multicenter MROC study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S3-07.

Prospective analysis of psychosocial outcomes after breast reconstruction: Cross-cultural comparisons of 1-year postoperative results

Breast reconstruction has been shown to improve quality of life in women following mastectomy for breast cancer. To date, there have been no published prospective reports looking at the effect nationality has on patient quality of life following breast reconstruction. Women from the USA, Sweden and Canada were recruited prior to reconstruction and followed prospectively for 1 year postoperatively. Thirteen centres with 24 plastic surgeons were involved. Preoperatively and 1 year postoperatively, women completed the Short Form-36 questionnaire. Data were analysed using t-tests and analysis of variance. A total of 313 women were followed up. American women who had immediate expander/implant surgery were compared with Swedish patients, whilst Americans who had undergone transverse rectus abdominis myocutaneous (TRAM) flap reconstructions were compared with Canadians. Women benefited from having breast reconstruction, but this improvement was not dependent upon country of origin. Swedish women reported less improvement in one subscale, that of general health, compared with American women (P=0.01). There were no cultural differences detected between Americans and Canadians.

Outcome of varicella pneumonitis in immunocompetent adults requiring treatment in a high dependency unit

OBJECTIVES

The incidence of varicella infection is increasing in adults, where primary pneumonitis is the main complication. Little information exists concerning treatment of those patients who require admission to a high dependency unit (HDU) facility. A study was performed to examine the risk factors for developing varicella pneumonitis (VP), to document disease progression and assess prognosis for patients with VP requiring HDU admission.

METHODS

A 10-year retrospective casenote review of patients admitted to the Regional Infectious Diseases Unit HDU. Varicella pneumonitis (VP) was defined as diffuse nodular shadowing on a chest X-ray (CXR) of a patient with a classical chickenpox rash. Severe pneumonitis was defined as an hypoxaemia index (pO2 in mmHG/FiO2) of less than 150 at any time during hospital stay. All patients were treated with intravenous acyclovir at a dose of 10 mg/kg.

RESULTS

A total of 33 patients were admitted to the HDU with VP over the study period, 30 were included in the study. Annual admission rates remained constant. Most patients (76.7%) had at least one recognised risk factor for severe VP: smoking 18/30, pregnancy 9/30, chronic lung disease 7/30. Twelve (40%) patients had severe VP, eight (26.7%) required assisted ventilation. The presence of greater than one risk factor (p < 0.02) was associated with progression to severe VP. There was one death: a 63-year-old man with a long history of chronic airflow limitation whose treatment had included domicillary long-term oxygen therapy. Nine (30%) patients developed secondary bacterial pneumonia; all recovered with appropriate antibiotic treatment. The period of stay in HDU for the majority of patients was short (mean 4.5 days).

CONCLUSIONS

The prognosis for severe adult VP with current available treatment is good. The only predictor on admission for severe VP is the presence of more than one recognised risk factor for developing VP.

Zidovudine phosphorylation determined sequentially over 12 months in human immunodeficiency virus-infected patients with or without previous exposure to antiretroviral agents

We sought to determine whether the intracellular activation of zidovudine (ZDV) varied over time and with previous antiretroviral exposure in human immunodeficiency virus-infected individuals and to examine whether there is an association between virological responses and intracellular phosphorylation. A total of 23 patients (12 treatment naïve, 11 previously treated with ZDV) who commenced ZDV as part of dual nucleoside therapy were prospectively monitored for 12 months or until withdrawal from the study. No association was observed between virological responses at 2 weeks and 3 months and ZDV phosphorylation. The mean intracellular concentrations of ZDV mono-, di-, and triphosphates did not change significantly over time or with previous ZDV exposure. The rate of formation of total ZDV phosphates was increased in patients with CD4 counts <100 cells/mm(3). Previous reports from in vitro cell culture experiments or cross-sectional cohort studies suggesting alterations of ZDV phosphorylation over time are not confirmed by this longitudinal study.

Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy

PURPOSE

To compare the rates of complications and patient satisfaction among breast cancer patients treated with mastectomy and tissue expander/implant reconstruction with and without radiotherapy.

METHODS AND MATERIALS

As part of the Michigan Breast Reconstruction Outcome Study (MBROS), breast cancer patients undergoing mastectomy with reconstruction were prospectively evaluated with respect to complications, general patient satisfaction with reconstruction, and esthetic satisfaction. Included in this study was a cohort of women who underwent breast reconstruction using an expander/implant (E/I). A subset of these patients also received radiotherapy (RT). At 1 and 2 years postoperatively, a survey was administered which included 7 items assessing both general satisfaction with their reconstruction and esthetic satisfaction. Complication data were also obtained at the same time points using hospital chart review. Radiotherapy patients identified in the University of Michigan Radiation Oncology database that underwent expander/implant reconstruction but not enrolled in the MBROS study were also added to the analysis.

RESULTS

Eighty-one patients underwent mastectomy and E/I reconstruction. Nineteen patients received RT and 62 underwent reconstruction without RT. The median dose delivered to the reconstructed breast/chest wall, including boost, was 60.4 Gy (range, 50.0-66.0 Gy) in 1.8- to 2.0-Gy fractions. With a median follow-up of 31 months from the date of surgery, complications occurred in 68% (13/19) of the RT patients compared to 31% (19/62) in the no RT group (p = 0.006). Twelve of 81 patients (15%) had a breast reconstruction failure. Reconstruction failure was significantly associated with experiencing a complication (p = 0.0001) and the use of radiotherapy (p = 0.005). The observed reconstruction failure rates were 37% (7/19) and 8% (5/62) for patients treated with and without radiotherapy, respectively. Tamoxifen was associated with a borderline risk of complications (p = 0.07) and a significant risk of reconstruction failure (p = 0.01). Sixty-six patients of the study group completed the satisfaction survey; 15 patients did not. To offset potential bias for patients not completing the survey, we analyzed satisfaction data assuming "dissatisfaction" scores for surveys not completed. In the analysis of patients with unilateral E/I placement, reconstruction failure was significantly associated with a lower general satisfaction (p = 0.03). Ten percent of patients experiencing a reconstruction failure were generally satisfied compared to 23% who completed E/I reconstruction. In addition, tamoxifen use was associated with a significantly decreased esthetic satisfaction (p = 0.03). Radiotherapy was not associated with significantly decreased general or esthetic satisfaction.

CONCLUSION

Irradiated patients had a higher rate of expander/implant reconstruction failure and complications than nonirradiated patients. Despite these differences, our pilot data suggest that both general satisfaction and patient esthetic satisfaction were not significantly different following radiotherapy compared to patients who did not receive RT. Although statistical power was limited in the present study and larger patient numbers are needed to validate these results, this study suggests comparable patient assessment of cosmetic outcome with or without radiotherapy in women who successfully complete expander/implant reconstruction.

TB PCR in the early diagnosis of tuberculous meningitis: evaluation of the Roche semi-automated COBAS Amplicor MTB test with reference to the manual Amplicor MTB PCR test

SETTING

Cecilia Makiwane Hospital, Mdantsane, Eastern Cape, Republic of South Africa.

OBJECTIVE

To assess the role of the semi-automated Roche COBAS AMPLICOR(TM)Mycobacterium tuberculosis PCR test in the diagnosis of tuberculous meningitis (TBM).

DESIGN

Eighty-three specimens of cerebrospinal fluid (CSF) were collected prospectively from 69 patients with suspected TBM. The COBAS AMPLICOR TB PCR test was compared with the manual AMPLICOR(TM)TB PCR test, clinical and cerebrospinal fluid (CSF) findings, direct ZN smear and radiometric TB culture.

RESULTS

CSF from 7/40 (17.5%) patients treated for TBM were positive by TB COBAS AMPLICOR(TM). The sensitivity of the test was not significantly different (p=0.375) from the manual TB AMPLICOR(TM)PCR test. The comparative sensitivities of the TB COBAS AMPLICOR(TM)PCR and the manual AMPLICOR PCR for detecting cases of definite and probable TBM from CSF collected within 9 days of commencing antituberculosis treatment were 40% and 60% respectively. All 29 patients not treated for TBM were negative by COBAS AMPLICOR(TM), giving a specificity of 100%.

CONCLUSION

The COBAS AMPLICOR(TM)TB PCR test is a rapid and highly specific diagnostic test for TBM. However, there was a non-significant trend favouring slightly greater sensitivity using the manual AMPLICOR(TM)TB PCR test.

Participants in HIV clinical trials in Europe

In recent years an increasing number of antiretrovirals have become available. In order to define the optimal treatment regimens an increasing number of clinical trials are needed. Our objective was to study the profile of participants in HIV clinical trials in Europe and learn from their experience and views. Between August 1996 and September 1997, self-administered anonymous questionnaires were distributed to people with HIV infection at inpatient and outpatient clinics in 11 European countries. One thousand three hundred and sixty-six people completed the questionnaire (50% response rate). Four hundred and twenty (31%) of the respondents reported that they had previously participated in at least one HIV clinical trial. The percentage of people who had taken part in a clinical trial varied widely between the different centres, from 12% in Athens to 61% in Antwerp and Brussels. A significantly higher participation rate was observed in the northern and central part of Europe compared with the south (respectively 40% vs 18%) and also among people with a higher income. Most people (92%) stated that they were 'well' or 'very well' informed prior to enrolment in the trial. However, 4% reported that they had not given written approval and 22% felt that they were pushed into participating. Only 21% stated that they were informed about the outcome of the study on its completion. The most important reason for non-participation (37% of the non-participants) was because a clinical trial had never been proposed. In conclusion, a majority of people with HIV infection in European HIV treatment reference centres were willing to participate in clinical trials. HIV clinical trials in Europe should adhere more strictly to universal ethical standards.

Plasma cysteine deficiency and decreased reduction of nitrososulfamethoxazole with HIV infection

The aim of these studies was to determine whether HIV-infected patients have a plasma thiol deficiency and whether this is associated with decreased detoxification of the toxic metabolites of sulfamethoxazole. Reduced, oxidized, protein-bound, and total thiol levels were measured in 33 HIV-positive patients and 33 control subjects by an HPLC method utilizing the fluorescent probe bromobimane. The reduction of sulfamethoxazole hydroxylamine and nitrososulfamethoxazole by plasma and the plasma redox balance in the presence of nitrososulphamethoxazole were also determined by HPLC. Reduced plasma cysteine was significantly (p<0.0001) lower in HIV-positive patients (13.0+/-3.0 microM) when compared with control subjects (16.9+/-3.0 microM). Although there was no difference in oxidized, protein-bound, and total cysteine, the thiol/disulfide ratios were lower in HIV-positive patients. Reduced homocysteine was elevated in patients. Plasma from HIV-positive patients was less able to detoxify nitrososulfamethoxazole than control plasma. These findings show that the disturbance in redox balance in HIV-positive patients may alter metabolic detoxification capacity, and thereby predispose to sulfamethoxazole hypersensitivity.

Delavirdine in combination with zidovudine in treatment of human immunodeficiency virus type 1-infected patients: evaluation of efficacy and emergence of viral resistance in a randomized, comparative phase III trial. The M/3331/0013B Study Group

We compared the activity of delavirdine (DLV) plus zidovudine (AZT) (n = 300) with that of AZT (n = 297) against human immunodeficiency virus type 1 in a randomized, double-blind, placebo-controlled trial. DLV exerted a transient antiviral effect, and mutations for resistance to DLV were found in more than 90% of subjects at week 12. The K103N mutation, which confers nonnucleoside reverse transcriptase inhibitor cross-resistance, was found in 85% of the patients.

Association analysis of drug metabolizing enzyme gene polymorphisms in HIV-positive patients with co-trimoxazole hypersensitivity

The use of co-trimoxazole in HIV-positive patients has been associated with a high frequency (40-80%) of hypersensitivity reactions. This has been attributed to the bioactivation of the sulphonamide component, sulphamethoxazole (SMX), to its toxic hydroxylamine and nitroso metabolites. The aim of this study was to determine whether functionally significant polymorphisms in the genes coding for enzymes involved in SMX metabolism influence susceptibility to SMX hypersensitivity. HIV-positive patients with (n = 56) and without (n = 89) SMX hypersensitivity were genotyped for allelic variants in CYP2C9, GSTM1, GSTT1, GSTP1 and NAT2 using polymerase chain reaction (PCR) and/or PCR-restriction fragment length polymorphism analysis. The CYP2C9*2/*3 genotype and CYP2C9*3 allele frequencies were nine- and 2.5-fold higher in the hypersensitive group compared to non-sensitive patients, respectively, although they were not statistically significant when corrected for multiple testing. There were no differences in the frequencies of the GSTM1 and GSTT1 null genotypes, and the slow acetylator genotype, between hypersensitive and non-sensitive patients, while GSTP1 frequency was lower (although non-significant) in the hypersensitive group [21% versus 32%, odds ratio (OR) = 0.5, Pc = 0.24]. Comparison of the genotype frequencies in HIV-positive and -negative patients showed that the NAT2 slow acetylator genotype frequency in the HIV-positive patients (74%) was significantly (Pc = 0.0003, OR = 2.3) higher than in control subjects (56%). Our results show that genetic polymorphisms in drug metabolizing enzymes are unlikely to be major predisposing factors in determining individual susceptibility to co-trimoxazole hypersensitivity in HIV-positive patients.

Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.

Determinants of patient satisfaction in postmastectomy breast reconstruction

In today's increasingly competitive health care marketplace, consumer satisfaction has become an important measure of quality. Furthermore, measures of satisfaction with treatment inteerventions are influential factors in determining patients' and payers' choices of health care. This study sought to evaluate satisfaction with postmastectomy breast reconstruction and to assess the effects of procedure type and timing on patient satisfaction. As part of the Michigan Breast Reconstruction Outcome Study, patients undergoing first-time mastectomy reconstruction were prospectively evaluated, including cohorts of women choosing expander/implant, pedicle TRFAM flap, and free TRAM flap procedures. Preoperatively and 1 year postoperatively, participants completed a questionnaire that collected a variety of health status information. The postoperative questionnaire had an additional seven items assessing both general satisfaction with reconstruction (five items) and aesthetic satisfaction (two items) as separate subscales. Patients were asked to respond to each item using a five-point Likert scale. Item responses ranged from 1, indicating high satisfaction, to 5, reflecting low satisfaction. In the data analysis, only patients responding with a 1 or 2 for all of the items within a subscale were classified as "satisfied" for the subscale. To assess the effects of procedure type (implant, pedicle TRAM flap, and free TRAM flap) and timing (immediate versus delayed) on satisfaction and to control for possible confounding effects from other independent variables, multiple logistic regression was employed. In our analysis, odds ratios and associated 95 percent confidence intervals were calculated for each independent variable in the regression. Statistical significance was designated at the p < or = 0.05 level. A total of 212 patients were followed during the period of 1994 to 1997, including 141 immediate and 71 delayed reconstructions. The study population consisted of 49 expander/implant, 102 pedicle TRAM flap, and 61 free TRAM flap reconstruction patients. The analysis showed a significant association between procedure type and patient satisfaction. TRAM flap patients (both free and pedicle) appeared to have significantly greater general and aesthetic satisfaction compared with expander/implant patients (p = 0.03 and 0.001, respectively). Furthermore, pedicle TRAM flap patients were more aesthetically satisfied than those with free TRAM flaps (p = 0.072). The other independent variables of age and procedure timing did not appear to significantly affect either general or aesthetic satisfaction. However, preoperative physical activity was positively correlated with general satisfaction at the p = 0.034 level. The choice of procedure seems to have a significant effect on both aesthetic and general patient satisfaction with breast reconstruction. In this study, autogenous tissue reconstructions produced higher levels of patient aesthetic and general satisfaction compared with implant techniques. Pedicle and free TRAM flap patients do not seem to differ significantly in general satisfaction. However, women receiving pedicle TRAM flaps reported greater aesthetic satisfaction compared with patients undergoing free TRAM flaps. Furthermore, patient age and procedure timing may not have an effect on patient satisfaction with breast reconstruction.

Double free-flap reconstruction of massive defects involving the lip, chin, and mandible

Two patients with massive, composite defects of the total lower lip, chin, and anterior mandible underwent double free-flap reconstruction. A fibular osteoseptocutaneous flap was used to reconstruct the mandible and floor of the mouth and a radial forearm fasciocutaneous composite flap, including the palmaris longus tendon, was used for total lower lip and chin reconstruction. Postoperatively, both patients had acceptable cosmesis, were orally competent, and recovered adequate mandibular function. Double free-flap reconstruction is indicated only in those circumstances in which composite tissue requirements or massive tissue defects preclude reconstruction with a single free-tissue transfer.

Implementation and evaluation of a clinical pathway for TRAM breast reconstruction

Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an Ftest. For all statistical tests, p values of < or = 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.039) and relative value units (p = 0.023). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.

Disseminated Penicillium marneffei in a patient infected with human immunodeficiency virus

A case of a 31-year-old man with systemic Penicillium marneffei infection acquired in Thailand and who developed endophthalmitis is described. This presentation has not previously been reported. He responded to combined treatment with intravenous and intravitreal amphotericin.

Breast reconstruction with TRAM flaps: normal and abnormal appearances at CT

In the transverse rectus abdominis musculocutaneous (TRAM) flap procedure, a portion of the abdominal wall is transposed to the chest as a pedicle or free flap. Patients who have undergone this procedure often subsequently undergo computed tomography (CT) for assessment of metastatic disease or unrelated pathologic conditions. CT scans obtained in patients who had undergone the TRAM flap procedure were reviewed to facilitate recognition of both the normal and abnormal postoperative CT appearances of the TRAM flap. In 28 reconstructed breasts in 21 patients, three general appearances were identified: type 1 (homogeneous fat attenuation) (n = 4), type 2 (fat attenuation with a thin, curvilinear soft-tissue band parallel to the skin surface) (n = 19), and type 3 (thick soft-tissue band parallel to the skin surface) (n = 5). A mass that arose in a type 2 breast 21 months after surgery represented recurrent cancer. A markedly thickened soft-tissue band in another patient represented a dry eschar with inflammation and fat necrosis. The rectus abdominis muscle was partially absent in eight cases and completely absent in 20 cases. Recognition of the normal postoperative appearance of the body wall helps avoid confusion with disease states and allows identification of abnormal conditions such as inflammation, infection, and recurrent breast cancer.

Intraoperative bacterial contamination in operations for joint replacement

All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty.

A study of anal intraepithelial neoplasia in HIV positive homosexual men

OBJECTIVES

To determine the prevalence of high grade anal intraepithelial neoplasia (HGAIN), the value of anal cytology in screening for HGAIN, and the characterisation of epidemiological factors and human papillomavirus (HPV) types.

METHODS

Prospective cohort study of HIV positive homosexual men. Subjects were interviewed, underwent STD, anal cytological, and HPV screening at enrolment and at subsequent follow up visits with anoscopy and biopsy at the final visit. 57 enrolled, average CD4 count 273 x 10(6)/l (10-588); 41 completed the cytological surveillance over the follow up period (181 visits, average follow up 17 months), 38 of these had anoscopy and anal biopsy.

RESULTS

Oncogenic HPV types were detected in 84% and high grade dyskaryosis in 10.5% (6/57) at enrollment. There was a 70% incidence of high grade dyskaryosis during follow up in patients with negative/warty or low grade dyskaryosis at enrollment. Anoscopy correlated with histology in high grade AIN lesions (sensitivity 91%, specificity 54%) and cytology was 78% sensitive (18/23) for HGAIN on biopsy.

CONCLUSIONS

AIN and infection with multiple oncogenic HPV types are very common among immunosuppressed HIV positive homosexual men. Apparent progression from low to high grade cytological changes occurred over a short follow up period, with no cases of carcinoma. All 23 cases of HGAIN were predicted by cytology and/or anoscopy. Future studies focusing on the risk of progression to carcinoma are needed before applying anal cytology as a screening tool for AIN in this population.

Predictors of patient satisfaction in an outpatient plastic surgery clinic

Although outcome measurement in medical care has traditionally included various aspects of clinical and functional status, patient satisfaction is another important metric in the assessment of health care quality. Determining which factors contribute most to patient satisfaction can assist health care providers in improving care. In an era of diminishing resources, satisfaction ratings can further aid third-party payers in determining who provides those services. The authors used the ordinal logistic regression method to develop a predictive model for patient satisfaction in an outpatient plastic surgery clinic. Consecutive patients who attended a university outpatient plastic surgery clinic were asked to complete the Visit Specific Patient Satisfaction Questionnaire (VSQ) after their clinic visit. Type of clinic (e.g., hand clinic, aesthetic clinic, breast clinic) and demographic variables like age, gender, race, and education were added to the questionnaire to control for possible confounding effects. The authors constructed an ordinal logistic regression model using the overall visit response as the dependent variable and the eight other response categories as independent variables. A total of 345 patients completed the VSQ, which takes each patient less than 2 minutes to complete. The patient response rate was more than 95%. Statistically significant predictors included (1) personal manner of physician (odds ratio [OR], 18.0; p = 0.0002), (2) time spent with physician (OR, 4.7; p = 0.0099), (3) length of time to get an appointment (OR, 4.6; p = 0.0055), and (4) explanation of what was done (OR, 3.9; p = 0.0263). There was no statistically significant association between overall satisfaction scores and the following factors: (1) length of wait in the clinic (OR, 2.7; p = 0.0747), (2) getting through to the clinic by phone (OR, 0.71; p = 0.5439), (3) convenience of the clinic's location (OR, 2.3; p = 0.1368), and (4) technical skills of the physician (OR, 1.0; p = 0.9974). The predictive model was adjusted for possible confounding due to the type of clinic and demographic variables. In this study the most important predictors of patient satisfaction were those related to efficient clinic operation (scheduling of appointments and clinic waiting time) and the quality of the patient-physician interaction. Clinic facilities (like clinic location and ease of phone contact) were not significant predictors. Because patients often have difficulty assessing the technical skills of physicians, this variable was not a significant predictor. To improve patient satisfaction in plastic surgery outpatient clinics, efforts and resources should be directed toward expedient and empathic delivery of care.

Mammographic appearance of recurrent breast carcinoma in six patients with TRAM flap breast reconstructions

PURPOSE

To determine the mammographic appearance of locally recurrent cancer in patients with breast reconstructions with transverse rectus abdominis musculocutaneous (TRAM) flaps after mastectomy for primary breast cancer.

MATERIALS AND METHODS

The mammograms and records of women treated for breast cancer with mastectomy and TRAM flap reconstruction who developed local recurrences from 1995 to 1997 were reviewed retrospectively. Eight cancers were identified in six women. Five women had palpable abnormalities, and the sixth had cancer detected at screening mammography at another institution. Mean age at recurrence was 48 years.

RESULTS

All eight cancers were visible on mammograms: four masses, two pleomorphic microcalcifications, and two masses with calcifications. Four of the eight were in the upper central portion of the breast. Before reconstruction, the original histologic diagnosis for all cases had been multifocal ductal carcinoma in situ. All recurrences were invasive cancer. Median time from the original diagnosis of breast cancer to diagnosis of recurrence was 42 months. Two of four patients who subsequently underwent axillary node dissection had metastatic disease in the lymph nodes. The single patient who underwent mammographic screening (elsewhere) had negative axillary lymph nodes.

CONCLUSION

The mammographic appearance of recurrent carcinoma in TRAM flap reconstructions is similar to that of primary breast cancer.

Is mammography useful in screening for local recurrences in patients with TRAM flap breast reconstruction after mastectomy for multifocal DCIS?

BACKGROUND

Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients.

METHODS AND RESULTS

We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography.

CONCLUSION

We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.

Influenza-like episodes in HIV-positive patients: the role of viral and 'atypical' infections

OBJECTIVES

To document viral and 'atypical' infections in HIV-positive patients and association with influenza-like symptoms.

PATIENTS AND METHODS

Monthly culture of urine, faeces and throat swabs in 63 HIV-positive patients (30 asymptomatic and 33 with AIDS-related complex/AIDS) over 5-27 months (with 1125 patient-months of follow-up), with further sample collections during influenza-like episodes. Standard viral detection methods were used. Throat swabs were assessed for Chlamydia sp. by culture and immunoblotting, and for Mycoplasma pneumoniae by polymerase chain reaction.

RESULTS

Viruses were detected in 15 (50%) and M. pneumoniae in nine (30%) out of 30 HIV-positive patients during an influenza-like illness. A close temporal relationship with symptoms was observed in 12 (40%) patients: cytomegalovirus in six (20%), M. pneumoniae in three (10%), herpes simplex virus in three (10%), and enterovirus in one (4%). Influenza-like symptoms were more frequent in asymptomatic HIV infection than in AIDS-related complex/AIDS patients (actuarial risk at 1 year, 63 versus 26%; P=0.002), particularly in those with CD4 cell counts >300 x 10(6)/l at enrolment (P=0.002). At least 44% (four out of nine) M. pneumoniae infections were asymptomatic and 78% (seven out of nine) were associated with prolonged excretion (2-17 months). Chlamydia sp. were not detected.

CONCLUSIONS

Influenza-like symptoms were more likely to be reported by HIV-positive patients at early stages of disease, possibly as a result of differences in immune responses to viral infection. There was a close association in 40% of cases between the development of symptoms and detection of cytomegalovirus, herpes simplex virus, enterovirus and M. pneumoniae (a previously unrecognized association).

Use of Roche AMPLICOR Mycobacterium tuberculosis PCR in early diagnosis of tuberculous meningitis

Several nucleic acid-based amplification tests are available for the detection of Mycobacterium tuberculosis, but few data are available on their use in the diagnosis of tuberculous meningitis (TBM). We performed a prospective study to assess the Roche AMPLICOR Mycobacterium tuberculosis PCR test (TB AMPLICOR) for use in the diagnosis of TBM and compared it with direct Ziehl-Neelsen staining of smears, radiometric culture for M. tuberculosis, and clinical and cerebrospinal fluid (CSF) findings. Eighty-three CSF specimens collected from 69 patients with suspected meningitis in South Africa were tested by TB AMPLICOR. On the basis of clinical and laboratory findings, 40 of these patients were treated for TBM and 29 patients were not treated for TBM. Ten CSF samples from 10 patients were positive by TB AMPLICOR. Seven of these 10 patients were classified as having definite TBM, 2 were classified as having probable TBM, and 1 was classified as having possible TBM. The sensitivity of TB AMPLICOR for detecting cases of definite and probable TBM in patients from whom CSF specimens had been collected less than 10 days into antituberculosis treatment was 60.0%. Specimens from all 29 patients not treated for TBM were negative by the TB AMPLICOR, giving a 100% specificity. TB AMPLICOR is therefore more sensitive than the combination of Ziehl-Neelsen staining of smears and radiometric culture for M. tuberculosis and is a rapid and highly specific diagnostic test for TBM.

Visceral leishmaniasis (Kala-azar) in two patients with HIV-1 infection: atypical features and response to therapy

Visceral leishmaniasis (VL) is a well recognized opportunistic infection in patients with HIV-1 infection, which may occasionally present with atypical features. We describe two patients with advanced HIV-1 infection (CD4<100/ mm3) in whom visceral leishmaniasis presented with atypical features, and their response to therapy. Atypical features of visceral leishmaniasis in the two infected patients include absence of fever, dissemination to the duodenal mucosa and to the skin as xanthoma-like lesions. Therapy and secondary prophylaxis remain unsatisfactory, and studies to evaluate combinations of amphotericin B and immunotherapy are needed.

The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among breast cancer survivors

PURPOSE/OBJECTIVES

To evaluate the effects of 10 weeks of aerobic exercise on depressive and anxiety symptoms and self-esteem of breast cancer survivors.

DESIGN

Experimental, crossover.

SETTING

Midwestern university town.

SAMPLE

Twenty-four breast cancer survivors (mean time following surgery 41.8 months; ranging from 1 to 99 months) recruited via mail and cancer support groups. The mean age of the sample was 48.9 years.

METHODS

Subjects were assigned randomly into exercise (EX), exercise-plus-behavior modification (EX + BM), and control groups. EX and EX + BM groups exercised aerobically four days/week at > or = 60% of age-predicted maximum heart rate for 10 weeks. Data were collected pretest, post-test, and crossover (12 weeks following post-test). Because pretest or post-test scores showed no statistical differences between EX and EX + BM groups, data were combined to form one group.

MAIN RESEARCH VARIABLES

Aerobic exercise (four days/ week; 30-40 minutes/session), depression, (Beck Depression inventory), anxiety (Speilberger State-Trait Anxiety Inventory), and self-esteem (Rosenberg Self-Esteem Inventory).

FINDINGS

Pre- to post-test analyses revealed that women who exercised had significantly less depression and state and trait anxiety over time compared to controls. After the crossover, the control group demonstrated comparable improvements in both depressive and state anxiety scores. Self-esteem did not change significantly. Subjects who received exercise recommendations from their physicians exercised significantly more than subjects who received no recommendation.

CONCLUSIONS

Mild to moderate aerobic exercise may be of therapeutic value to breast cancer survivors with respect to depressive and anxiety symptoms but not to self-esteem. A physician's recommendation to exercise appears to be an important factor in a patient's exercise adherence.

IMPLICATIONS FOR NURSING PRACTICE

To Improve depressive and anxiety symptoms following breast cancer surgery, healthcare professionals should consider recommending mild to moderate exercise.

Successful diagnosis and management of cytomegalovirus carditis

Cytomegalovirus (CMV)-associated carditis in the immunosuppressed patient carries a 60% mortality. Underlying pathogenesis is poorly understood but may involve either direct viral invasion or autoimmune cardiac damage triggered in response to the infection. Specific anti-cytomegalovirus therapy and/or anti-inflammatory drugs have been shown to benefit in cases where an early diagnosis was established. We report an unusual case of endo-pericarditis which was temporally related to acute cytomegalovirus infection diagnosed by the immediate early antigen detection in cell culture on whole blood.

Tumour necrosis factor c2 microsatellite allele is associated with the rate of HIV disease progression

BACKGROUND

The rate of immunological deterioration and progression to AIDS differs markedly between HIV-positive individuals, and may be influenced by cofactors, HIV phenotype and host T-cell response. Tumour necrosis factor (TNF)-alpha and lymphotoxin stimulate HIV replication and may induce apoptosis of HIV-infected and uninfected lymphocytes in vitro, thus accelerating disease progression and CD4 depletion. Variability in TNF production between individuals is to a degree genetically determined and may be predicted from polymorphisms of microsatellite regions surrounding the human TNF gene locus.

METHODS

We examined TNf microsatellite polymorphisms in 24 HIV-positive patients with slower disease progression (CD4 count > 400 x 10(6)/l at > or = 6 years), 20 HIV-positive patients with faster progression (CD4 count < 200 x 10(6)/l within 5 years) and 109 healthy controls resident in north-west England. Typing was performed by polymerase chain reaction amplification of TNF a, b, c and d microsatellites and alleles were defined using fluorescence-based semi-automated microsatellite mapping techniques.

RESULTS

No significant differences in TNF a, b and d allele frequencies were observed between faster and slower progressors, or with healthy controls. The frequency of the TNF c2 allele was significantly different between HIV-positive slower (60.9%) and faster (15%) progressors (P = 0.002) with an odds ratio of 0.1 (95% confidence interval, 0-0.6). TNF c2 was also less frequent in faster progressors than in healthy controls (45.9%, P = 0.006) with an odds ratio of 0.2 (95% confidence interval 0-0.8).

CONCLUSIONS

This is the first report demonstrating a strong association between the TNF c2 allele and the rate of HIV progression. Although it is possible that this finding may have arisen as a result of linkage disequilibrium with other alleles within the major histocompatibility complex that exert a more powerful effect upon progression, evidence is mounting to suggest that both TNF-alpha and lymphotoxin are closely involved in HIV disease progression and CD4 depletion. Our results serve to highlight the potential importance of genetic polymorphism, particularly of the TNF locus, in influencing the progression of HIV infection.

The effect of zidovudine dose on the formation of intracellular phosphorylated metabolites

OBJECTIVES

Zidovudine (ZDV) requires intracellular phosphorylation to ZDV triphosphate (ZDV-TP) prior to the inhibition of HIV replication. The effect of ZDV dose on the formation of intracellular phosphorylated metabolites may help define the optimum daily dose of ZDV, which is still unknown.

DESIGN AND METHODS

The plasma and intracellular phosphorylated metabolite concentrations of ZDV were determined over a 12 h period following oral administration of 100 and 300 mg ZDV to 10 HIV-seropositive patients at steady state during two dosing regimens (i.e., 100 mg three times daily and 300 mg twice daily). The intracellular ZDV phosphates, ZDV monophosphate (ZDV-MP), ZDV diphosphate (ZDV-DP) and ZDV-TP were measured in peripheral blood mononuclear cells using a combination of high-performance liquid chromatography and radioimmunoassay.

RESULTS

There was a greater than threefold increase in maximum plasma concentration (Cmax) following 300 mg ZDV when compared with 100 mg ZDV (mean +/- SD, 2.59 +/- 0.52 versus 0.70 +/- 0.14 mumol/l). The area under the concentration time curve (AUC0-12 h) was also significantly increased (4.59 +/- 0.79 versus 1.42 +/- 0.51 mumol/l x h) following 300 mg ZDV dose. For total intracellular ZDV phosphate metabolites the AUC0-12 h was doubled (7.64 +/- 3.67 versus 3.71 +/- 1.83 pmol/10(6) cells x h) in patients taking 300 mg ZDV compared with 100 mg. The AUC0-12 h for ZDV-MP was significantly increased at the higher dose (6.47 +/- 3.14 versus 2.77 +/- 1.70 pmol/10(6) cells x h), whereas the active moiety ZDV-TP was variable and not significantly different (0.42 +/- 0.42 versus 0.61 +/- 0.81 pmol/10(6) cells x h) following 100 and 300 mg ZDV.

CONCLUSIONS

Administration of 100 mg ZDV orally produces significantly less of the potentially toxic metabolite, ZDV-MP, and comparative, although variable, concentrations of the active metabolite ZDV-TP when compared with 300 mg ZDV orally. This finding supports clinical data indicating the efficacy of low-dose (300 mg daily) ZDV. The measurement of intracellular phosphorylated metabolites advances our understanding of the clinical pharmacology of ZDV.

Lack of skin test reactivity to common mycobacterial antigens in human immunodeficiency virus infected individuals with high CD4 counts

BACKGROUND

T cell response to mycobacterial antigens may be directed against those antigens common to all mycobacteria (group i), those restricted to slow (group ii) or fast growers (group iii), or those which are species- or subspecies-specific (group iv). These responses were assessed by skin testing patients infected with the human immunodeficiency virus (HIV) and healthy controls with reagents derived from different strains of mycobacteria.

METHODS

Skin test responses to new tuberculins prepared from Mycobacterium tuberculosis, M avium serotypes 4 and 8, and either M intracellulare or M flavescens antigens were evaluated prospectively in 51 HIV infected patients and 67 healthy controls.

RESULTS

Assessment of induration at 72 hours showed absence of skin test response to common mycobacterial antigens in all 27 HIV positive patients with CD4 counts of > or = 400/mm3 (range 400-1594, median 540) compared with 27% reactivity in controls; complete anergy was demonstrated in 24 patients with CD4 counts of < 400/mm3. By contrast, no difference in species or subspecies-specific responses was found between healthy controls and HIV positive patients with CD4 counts of > or = 400/mm3.

CONCLUSIONS

Subsets of CD4+ T helper cells are instrumental in determining the balance between cell-mediated and humoral immunity. One T helper subset (TH1) produces cytokines that increase cellular immunity and is stimulated by group i common mycobacterial antigens. Lack of this response, but preservation of responses to species-specific antigens while CD4 counts are near normal, may indicate an early failing of TH1 immunity and explain the increased susceptibility of HIV positive patients to mycobacterial infection early on in the evolution of their HIV infection.

Outcomes research: a primer for plastic surgeons

The growing emphasis on cost-effectiveness in the United States health care industry has highlighted the need for comprehensive outcomes research in a variety of medical specialties. Currently, there is a relative paucity of reliable data characterizing the long-term results of many medical and surgical treatments. This shortage of outcomes research is particularly acute within plastic surgery where the benefits of treatment are often intangible and notoriously difficult to measure. In evaluating the effectiveness of medical treatment, conventional clinical research has focused primarily on morbidity and mortality as the outcomes of interest. In contrast, current outcome studies assess the results of interventions from the patient's perspective, measuring the impact of medical care on physical functioning, well-being, and quality of life. The resulting data can assist consumers, providers, and payers in making more appropriate health care decisions. As the outcomes movement has matured, it has evolved into two major areas of study: effectiveness research that evaluates the relationships between specific medical interventions and outcomes of care, and quality assessment that seeks to provide the best outcomes at the most reasonable costs. This review details the origins and trends of current outcomes research, examining the implications of this movement for plastic surgery. The growing impact of outcomes data on treatment guideline formulation in both the public and private sectors is also described. Finally, a brief review of outcomes study design, including definition of variables and selection of instruments, is presented.

Utility of PCR in diagnosing pulmonary tuberculosis

At present, the rapid diagnosis of pulmonary tuberculosis rests with microscopy. However, this technique is insensitive and many cases of pulmonary tuberculosis cannot be initially confirmed. Nucleic acid amplification techniques are extremely sensitive, but when they are applied to tuberculosis diagnosis, they have given variable results. Investigators at six centers in Europe compared a standardized PCR system (Amplicor; Roche) against conventional culture methods. Defined clinical information was collected. Discrepant samples were retested, and inhibition assays and backup amplification with a separate primer pair were performed. Mycobacterium tuberculosis complex organisms were recovered from 654 (9.1%) of 7,194 samples and 293 (7.8%) of 3,738 patients. Four hundred fifty-two of the M. tuberculosis isolates from 204 patients were smear positive and culture positive. Among the culture-positive specimens, PCR had a sensitivity of 91.4% for smear-positive specimens and 60.9% for smear-negative specimens, with a specificity of 96.1%. Analysis of 254 PCR-positive, culture-negative specimens with discrepant results revealed that 130 were from patients with recently diagnosed tuberculosis and 94 represented a presumed laboratory error. Similar analysis of 118 PCR-negative, culture-positive specimens demonstrated that 27 discrepancies were due to presumed uneven aliquot distribution and 11 were due to presumed laboratory error; PCR inhibitors were detected in 8 specimens. Amplicor enables laboratories with little previous experience with nucleic acid amplification to perform PCR. Disease in more than 60% of the patients with tuberculosis with smear-negative, culture-positive specimens can be diagnosed at the time of admission, and potentially all patients with smear-positive specimens can immediately be confirmed as being infected with M. tuberculosis, leading to improved clinical management.

Evaluations of aesthetic results in breast reconstruction: an analysis of reliability

This study evaluated the reliability of three commonly used measures of aesthetic outcomes of breast surgery: a four-point ordinal scale of overall aesthetics, five four-point subscales, and a visual analogue scale. Fifty patients were randomly selected from women who underwent breast reconstruction surgery at University of Michigan hospitals between July 1989 and May 1993. Postoperative photographs of these patients were provided to three plastic surgeons, who were asked to rate the photographs using the three methods. The same process was repeated 4 weeks later. Intrarater and interrater reliability ranged from poor to good for the three methods, with the subscales showing the highest reliability. The lowest reliability occurred for those scales with the least-explicit rating criteria. Without explicit criteria, raters must develop and use their own criteria, which are likely to differ for each rater. Separating the various components of the aesthetic results of breast surgery into different subscales helps make the rating criteria more explicit. Scales with demonstrated reliability are critical for ensuring comparability of results across studies.

Intracellular glutathione in the peripheral blood cells of HIV-infected patients: failure to show a deficiency

OBJECTIVE

To determine whether HIV-infected patients have a deficiency of intracellular glutathione (GSH) in peripheral blood mononuclear cells (PBMC) and erythrocytes.

DESIGN

Initial experiments determining the stability of intracellular GSH preceded the measurement of GSH levels in 33 HIV-positive patients and 40 control subjects within 1 h of isolation of their blood cells. In addition, the susceptibility of erythrocytes to dapsone hydroxylamine-induced methaemoglobinaemia was evaluated.

METHODS

GSH levels were determined by an high-performance liquid chromatography method utilizing a fluorescent probe, monobromobimane. The bimane-GSH adduct formed in PBMC was also characterized by mass spectrometry. Methaemoglobin formation on exposure to dapsone hydroxylamine was determined spectrophotometrically.

RESULTS

GSH levels remained stable for only 1 h after cell isolation, thereafter showing a decrease of 20 and 60% at 4 and 24H, respectively, There was no difference in the GSH levels in PBMC and erythrocytes of the HIV-positive patients compared with controls. The GSH levels were not related to the disease stage or to CD4+ cell counts. There was no difference in GSH levels in PBMC taken from trimethoprim-sulphamethoxazole-hypersensitive and non-hypersensitive patients. Methaemoglobinaemia on exposure of erythrocytes to dapsone hydroxylamine was concentration-dependent, but there was no significant difference between patients and controls.

CONCLUSION

In contrast to previous studies, no deficiency of intracellular GSH in the PBMC and erythrocytes of HIV-infected patients was found. The discrepancy between studies may be methodological reflecting the instability of GSH, which requires prompt sample analysis.

Diagnosis of silicone gel breast implant rupture by ultrasonography

To prospectively evaluate the efficacy of ultrasonography in the diagnosis of ruptured silicone gel breast implants, 98 patients (192 implants) underwent preoperative breast ultrasonography prior to silicone gel breast implant removal. The prevalence of implant rupture confirmed at surgery in this group of patients was 62 of the 192 implants (32 percent). Of the 60 implants diagnosed as ruptured by ultrasonography, 46 were confirmed as having visible defects at surgery (true positive) for a positive predictive value of 77 percent. Of the 132 implants diagnosed as intact by ultrasonography, 116 were confirmed as intact at surgery (true negative) for a negative predictive value of 88 percent. Overall, the sensitivity of ultrasonography for implant rupture was 74 percent, and the specificity was 89 percent. These findings demonstrate that ultrasonography is an effective imaging modality for the diagnosis of silicone gel breast implant rupture. Compared with mammography, ultrasonography appears to offer superior sensitivity and specificity without radiation exposure or discomfort. Although magnetic resonance imaging has shown considerable promise in the diagnosis of implant rupture, ultrasonography provides comparable sensitivity at a fraction of MRI's cost.

Prevalence of cortisol deficiency in late HIV disease

In order to determine the prevalence of cortisol deficiency in advanced HIV disease and to examine whether it may be predicted by clinical features or biochemical abnormalities, we conducted a prospective study which assessed responses to a rapid ACTH stimulation test (short-duration synthetic corticotrophin test, synacthen test) in HIV-positive patients with a CD4 count of < or = 50 x 10(6)/l. Subjective fatigue, postural drop in blood pressure, electrolyte changes, presence of concurrent opportunist infection and drug treatment were recorded. Cortisol responses were defined as 'normal' (a post stimulation cortisol level > or = 450 nmol/l), 'abnormal' (post stimulation cortisol level < 350 nmol/l) or 'impaired' (an intermediate response). Of 49 patients tested (42 male, seven female), a suboptimal response (abnormal or impaired) was found in 14 (29%) and frank insufficiency in eight (16%). Cortisol deficiency was not predicted by postural drop in blood pressure, biochemistry or symptoms of fatigue. Patients with an impaired/abnormal test were not more likely to have cytomegalovirus or mycobacterial disease but were more likely to be taking megestrol acetate (P = 0.05, Fisher's exact test). Two of three patients with initially normal tests developed impaired/abnormal cortisol responses on re-testing 6-9 months later. Cortisol deficiency is common in late stage HIV disease, but symptoms of fatigue and postural hypotension, as well as biochemical findings, are poor predictors of cortisol deficiency. We found good subjective response to therapy. Routine screening by a rapid ACTH stimulation test is recommended in HIV-positive patients with CD4 count < or = 50 x 10(6)/l. Re-testing at regular intervals may be necessary. The interaction between megestrol acetate, cortisol metabolism and synacthen testing requires further investigation.

Serodiagnosis of pericardial tuberculosis

The AIDS epidemic has led to the resurgence of tuberculosis. Extrapulmonary manifestations may appear in over half of the patients who are dually infected. This has resulted in a rising incidence of tuberculous pericarditis in several parts of Africa such as Tanzania. We tested a solid-phase antibody competition sandwich ELISA (SACT-SE) as a potential means of diagnosing tuberculous pericarditis. Fifty-one African patients with clinically diagnosed tuberculous pericardial effusion (of whom 25 had confirmation by pericardial fluid culture) were tested using a monoclonal antibody (CDC/WHO ref. no. IT39) which was raised against a specific epitope on the Mycobacterium tuberculosis 30 kDa antigen. All but one patient had negative sputum microscopy for acid-fast bacilli. A sensitivity of 61% (at 96% specificity) was achieved. Sera from 25 African patients with smear-positive tuberculosis were also examined; of which 20 tested positive (sensitivity 80%). This is the largest study to date on the potential application of serology in diagnosing pericardial tuberculosis.

Immediate transverse rectus abdominis musculocutaneous flap reconstruction after mastectomy

BACKGROUND

This study examines the early and long-term outcomes of immediate transverse rectus abdominis musculocutaneous (TRAM) reconstruction of the breast after mastectomy.

STUDY DESIGN

The records of all patients undergoing mastectomy and immediate TRAM breast reconstruction between December 1989 and October 1993 were reviewed retrospectively using hospital and breast care center databases.

RESULTS

Fifty-three patients underwent a total of 73 immediate TRAM breast reconstructions. Reconstruction was successfully completed in all patients, using 46 pedicle flaps and 27 free tissue transfers. There were no flap losses or cardiopulmonary complications. Overall, the complication rate was 26 percent (29 percent for pedicle TRAM and 22 percent for free TRAM flaps). The median follow-up period among the 53 patients was 22.6 months (range of three to 48 months). All patients employed preoperatively resumed their occupations postoperatively.

CONCLUSIONS

Our experience indicates that immediate TRAM breast reconstruction is a safe and viable option for patients seeking reconstruction at the time of mastectomy.

Controversies in anti-retroviral therapy of adults

Much controversy surrounds the use of antiretroviral drugs in HIV-infected patients. The many studies involving large numbers of patients that have been and are being conducted have raised as many questions as they have sought to answer. Given that no cure exists and that all clinically available drugs have only limited activity despite their high toxicity, the question of which drug (or combination of drugs) to use, and in whom, continues to vex both the clinician and the patient. Only three specific antiretroviral agents are currently licensed for use: zidovudine (ZDV), didanosine (dideoxyinosine, ddI) and zalcitabine (dideoxycytidine, ddC). This article reviews the major studies comparing the clinical efficacy of these drugs and the possible benefits of adding acyclovir to zidovudine therapy. The questions of when to begin antiretroviral therapy and the role of combination chemotherapy are discussed. Whenever possible, 'clinical' endpoints (death or clinical progression) are distinguished from 'softer' endpoints (surrogate markers of progression, such as the CD4 lymphocyte count) in the studies reviewed. Recommendations for the use of antiretroviral agents based on currently available published data are made.

Growth hormone deficiency coupled with hypogonadism in AIDS

Both growth hormone and sex steroid deficiencies are known to affect quality of life adversely. Hypogonadism is not infrequent in patients with AIDS and due mostly to hypothalamic or end-organ failure. The prevalence of GH deficiency is unknown. We report two cases of GH deficiency in AIDS, one of which was associated with gonadotroph failure. The significance of GH deficiency in HIV infection in terms of its potential effects on disease progression is discussed. Further studies are required to assess the prevalence of GH deficiency and to clarify its role in the immunopathogenesis of AIDS.

Humoral response to mycobacterial heat shock proteins in patients with constrictive pericarditis caused by tuberculosis and its implications for pathogenesis

Tuberculous pericarditis is one of the commonest causes of cardiac failure in Transkei and the surrounding regions in southeast Africa. About 20% of patients with clinically diagnosed tuberculous pericardial effusion go on to develop pericardial fibrosis (i.e., construction), a complication which is associated with significant mortality and morbidity. The pathological mechanisms underlying this aberrant inflammatory response are poorly understood, and there is a lack of reliable pointers (clinical or laboratory) in predicting the likelihood of development of constriction. We studied the humoral response to mycobacterial heat shock proteins (65 and 71 kDa) in 25 patients with culture-positive tuberculous pericardial effusion and found a significant correlation between high anti-mycobacterial hsp60 antibody titers (before treatment) and subsequent development of fibrosis (P = 0.035 by logistic regression), which is independent of the effect of the use of prednisolone as adjuvant therapy. Possible mechanisms underlying the pathogenesis of pericardial constriction in tuberculosis are postulated.

Severe community acquired pneumonia associated with a desquamating rash due to group A beta-haemolytic streptococcus

In recent years frequent and severe infections due to group A beta-haemolytic streptococci have been recognised with increasing frequency. Group A streptococcal pneumonia remains a rare disease occurring sporadically in contrast to epidemics in the past. The association between group A streptococcal pneumonia and a desquamating skin rash typical of scarlet fever has rarely been reported.

Successful treatment of AIDS-related cryptosporidial sclerosing cholangitis

OBJECTIVE

Cryptosporidium is a well recognized cause of AIDS-related sclerosing cholangitis for which no efficacious therapy exists at present. We evaluated the efficiency of the combination of paromomycin and letrazuril in the treatment of this condition.

CASE REPORT

We report a case of cryptosporidial cholangitis in a patient with AIDS who responded to treatment with intravenous paromomycin followed by oral letrazuril as maintenance therapy.

CONCLUSION

The combination of paromomycin and letrazuril should be considered in the treatment of AIDS-related sclerosing cholangitis.